OSA: Only the Beginning of the Riddle of Daytime Sleepiness

Patients with OSAS who also have undiagnosed RLS will continue to have insomnia and EDS symptoms despite adequate treatment with continuous positive airway pressure (CPAP), he said. Further, not diagnosing RLS patients before a sleep study might decrease the effectiveness of the study because the patient may be unable to sleep due to RLS symptoms, he added. If the patient is having excessive limb movements, he or she may not be able to get into full stages of sleep, and you may not get as good an assessment of the sleep disorder as you could otherwise.

With all sleep disorder patients, otolaryngologists may find it helpful to ask about the patients’ sleep hygiene when obtaining the history, he said. The physician should ask when the patient goes to sleep and wakes up, and whether he or she has trouble falling asleep, staying asleep, or both. Patients with RLS will frequently complain of sleep-onset insomnia or difficulty in falling back to sleep after waking up, he said. Because of the prevalence of RLS, I routinely ask patients if they have problems with an uncomfortable feeling in the leg. That question will usually identify patients who have RLS.

An RLS diagnosis does not require polysomnography, he said. If the history includes an uneasy feeling in the legs, a sensation of restlessness that is worse in the evening, improved with activity, and made worse by inactivity, the diagnosis can be made. If you have a patient with RLS, identify and treat the condition prior to sleep study for sleep-disordered breathing, he said. Some of the medications typically used are dopaminergic agents such as pramipexole (Mirapex) and ropinirole (Requip).

Knowing about non-OSAS sleep disorders will help otolaryngologists have a complete understanding of sleep medicine, according to Jordan S. Josephson, MD, Director of the New York Nasal and Sinus Center, who was not on the panel. He pointed out that OSAS still needs to be identified and managed.

OSAS is one of largest reasons for fatigue that leads to automobile accidents, and is associated with heart disease and stroke, he said. Dr. Josephson agreed with the panelists that comprehensive treatment is necessary when an OSAS patient has multiple sleep disorders. When you identify problems [or] obstructions contributing to sleep apnea, then treat them all, not just one, as [treating only one] will lead to failure. Furthermore, the treatment in vogue that week may not be the procedure that your particular patient requires, so accurate diagnosis and targeted therapy is key to success in relieving the OSAS.